EVALUATION OF ADULTS’ WHOLE GRAIN CONSUMPTION AND THEIR ATTITUDES ABOUT WHOLE GRAINS
GÜLBİN IŞIKLI
UNDERGRADUATE THESIS STUDY
INSTRUCTOR
ASIST. PROF. DR. MÜJGAN ÖZTÜRK
EASTERN MEDITERRANEAN UNIVERSITY
JUNE, 2021
FAMAGUSTA, NORTH CYPRUS
OBJECTIVE: The aim of this study is to determine the whole grain consumption of adults and their attitudes and thoughts about whole grains.
METHODS: This study was done with 19-65 years old 50 adults in Aydın who don’t have any physical or psychologic problem. All the participants voluntarily attended to the study. Adults’ whole grain consumption and their attitudes about whole grains were assessed using a questionnaire. The questionnaire consists of 4 parts including demographic characteristics, anthropometric measurements, knowledge and attitude to whole grains and food frequency questionnaire. Anthropometric measurements include weight and height, BMI, waist and hip circumference were measured for each participant. Knowledge and attitude to whole grains evaluated with the answers of the participants "yes", "no" and/or "do not know". The frequency of consumption is evaluated by every meal, every day, once or twice a week, 2-3 times a week, 3-4 times a week, 5-6 times a week, once a two week, once a month and never answers.
RESULTS: All the participants (100%) who had normal weight or overweight heard about term of whole grain. However, only 66,7% of overweight or obese participants and 62,5% of participants who had normal BMI knew the definition of whole grain. Besides, 94% of total participants described whole grain as 100% whole wheat. Also, 84,0% of total participants like the taste of whole grain and 94,4% of these participants were overweight and 78,1%of these participants were normal weight. Moreover, %88,9 of overweight and 71,9% participants with normal weight didn’t prefer taste of whole grain bread compared to taste of white bread. On the other hand, participants who said healthy for whole grain bread, the consumption was for normal weight and overweight participants 26,03±32,50 g and 26,09≥±32,19 g respectively. Furthermore, participants who thoughts delicious for whole grain bread, overweight participants consumed 26,03≥±32,50 g and healthy weight participants consumed 25,35±23,40 g and there is no significant difference between overweight and healthy participants.
CONCLUSION: In conclusion, consumers’ consumption doesn’t change according to BMI except than rye bread. Consumers’ thoughts about whole grains differ according to BMI. Daily consumption amount of whole grain products doesn’t differ according to BMI but it differs according to gender. Consumers’ who thought whole grain bread delicious and/or healthy daily consumption amount of whole grain bread doesn’t differ according to BMI.
Consumers should be informed about the importance of whole grains in healthy eating habits. Promotion of whole grain products which frequently consumed such as bread, pasta and rice should be increased in the markets to increase daily consumption of whole grain products.
KEY WORDS: Whole grain, attitude, knowledge, consumption, BMI
To My Family and AllMy Loed Ones
I would like to thank warmly and gratitude to Asist. Prof. Dr. Müjgan ÖZTÜRK for guiding me with her vast knowledge and experience at every stage of my thesis work and for her support and understanding throughout the whole process.
Also, I would like to thank my dear family for their financial and moral support throughout my education.
TABLE OF CONTENTS
ABSTRACT.. i
DEDICATION.. i
ACKNOWLEDGEMENT.. i
1. INTRODUCTION.. 1
2. GENERAL INFORMATION.. 1
2.1. DEFINITION OF WHOLE GRAINS. 1
2.2. CONSUMER’S ATTITUDES TO WHOLE GRAINS. 1
2.3. DIET AND WHOLE GRAINS. 1
2.3.1. THE NUTRITIONAL COMPOSITION OF WHOLE GRAINS AND THEIR HEALTH BENEFITS. 1
2.4. RELATIONSHIP OF WHOLE GRAINS WITH DISEASES AND PUBLIC HEALTH 1
2.4.1. OBESITY.. 1
2.4.2. TYPE 2 DIABETES. 1
2.4.3. HYPERTENSION.. 1
2.4.4. CARDIOVASCULAR DISEASE.. 1
3. METHODOLOGY.. 1
3.1. THE PLACE AND TIME OF STUDY.. 1
3.2. POPULATION OF STUDY.. 1
3.3. DATA COLLECTION.. 1
3.3.1. GENERAL INFORMATION COLLECTION.. 1
Table 3.1 BMI Classification (WHO, 2020) 1
Table 3.2. Waist to Hip Ratio Chart (WHO, 2020) 1
Table 3.3. Waist to Height Ratio Chart (TÜBER, 2016). 1
3.3.2. WHOLE GRAIN KNOWLEDGE.. 1
3.3.3. ATTITUDES TO WHOLE GRAINS. 1
3.3.4. FOOD FREQUENCY QUESSTIONNAIRE SPECIFIED FOR GRAINS 1
3.4. DATA ANALYSIS. 1
4. RESULTS. 1
Tablo 4.1. Distribution of general information about consumers. 1
Table 4.2. Distribution of consumers according to lifestyle habits and health status. 1
Table 4.3. Distribution of age according to gender 1
Table 4.4. Distribution of consumer’s anthropometric measurements according to gender 1
Table 4.5. Distribution of consumer’s knowledge about whole grain according to BMI 1
Table 4.6. Distribution of recognizing whole grain products according to BMI. 1
Table 4.7. Consumer’s knowledge about recommended portion of whole grain consumption according to BMI. 1
Table 4.8. Distribution of consumer’s thoughts about the properties of whole grains according to BMI 1
Table 4.9. Comparison of daily grain consumption according to BMI. 1
Table 4.10. Comparison of daily grain consumption according to gender 1
Table 4.11. Distribution of whole grain bread consumption who thought healthy and/or delicious according to BMI. 1
5. DISCUSSION.. 1
5.1. SOCIODEMOGRAPHIC FEATURES. 1
5.2. KNOWLEDGE LEVEL OF WHOLE GRAINS. 1
5.3. ATTITUDE AGAINST WHOLE GRAINS. 1
5.4. GRAIN CONSUMPTION FREQUENCY.. 1
6. CONCLUSION.. 1
7. RECOMMENDATIONS. 1
REFERENCES. 1
9. APPENDIX.. 1
9.1. QUESTIONNAIRES. 1
ABBREVIATIONS
FDA U.S. Food and Drug Administration
AACC American Association for Clinical Chemistry
DGA Dietary Guidelines Advisory
NHANES National Health and Nutrition Examination Survey
WHO World Health Organization
SPSS Statistical Package for Social Sciences
BMI Body Mass Index
LIST OF FIGURES
Figure 2.1. The primary parts of Whole-wheat grain………………………………11
Figure 2.2. Whole grain intake of men in the world, 2010 (g/day)………………...12
Figure 2.3. Whole grain intake of women in the world, 2010 (g/day)………………13
LIST OF TABLES
Table 3.1 BMI Classification (WHO, 2020)………………………………………22
Table 3.2. Waist to Hip Ratio Chart (WHO, 2020)………………………………..22
Table 3.3. Waist to Height Ratio Chart (TÜBER, 2016)…………………………..23
Tablo 4.1. Distribution of general information about consumers………………….25
Table 4.2. Distribution of consumers according to lifestyle habits and health status………………………………………………………………………………...26
Table 4.3. Distribution of age according to gender………………………………...26
Table 4.4. Distribution of consumer’s anthropometric measurements according to gender……………………………………………………………………………….27
Table 4.5. Distribution of consumer’s knowledge about whole grain according to BMI…………………………………………………………………………………27
Table 4.6. Recognizing of whole grain products according to BMI…………………………………………………………………………………28
Table 4.7. Consumer’s knowledge about recommended portion of whole grain consumption according to BMI…………………………………………………….30
Table 4.8. Distribution of consumer’s thoughts about the properties of whole grains according to BMI…………………………………………………………………..31
Table 4.9. Comparison of daily grain consumption according to BMI……………32
Table 4.10. Comparison of daily grain consumption according to gender………...34
Table 4.11. Distribution of whole grain bread consumption who thought healthy and/or delicious according to BMI…………………………………………………36
1. INTRODUCTION
Cereals play an important role in nutrition (Marshall et al., 2020). Grain-based diets provide most of the world's energy and nutrient requirements, supplying 25-50% of the daily calorie intake in the world. Dietary guidelines recommends 40-65% of energy as carbohydrates, with 65% considered by some to be high around the world (Julie Miller Jones et al., 2020).
Whole cereal grains are members of the Poaceae or Gramineae families (Beloshapka et al., 2016) and it has been a part of the human diet for millions of years (Shaltout et al., 2020). Foods made from whole grains are known to contain less starches and calories, more micronutrients and phytochemicals which can provide major health benefits instead of refined grain foods (Cho et al., 2013). Its fractions, bran and germ, consisting of specific bioactive components that promote wellbeing. The bran is the multi-layered outer skin that includes fiber, minerals, vitamins and bioactive compounds, among which it is of concern to identify phenolic acids as bioactive phytochemicals for significant effects on humans (Călinoiu & Vodnar, 2018).
Whole grain foods are often recognized by the use of food labeling and by their appearance and color (Foster et al., 2020). In the USDA/Health and Human Services Dietary Guidelines Advisory (DGA) Expert Panel report, examples of whole-grain foods and ingredients include brown rice, oatmeal, whole oats, cracked wheat, popcorn, whole rye and whole wheat (Cho et al., 2013), which has rich source of various bioactive compounds and dietary fibers (Jawhara et al., 2019). However, consumers may become confused while choosing refined grains instead of whole grain sources by mistake without sufficient knowledge of how to read a label and classify whole grains (Foster et al., 2020).
The inverse correlation between the daily consumption of whole grain foods and the risk of heart disease, some forms of cancer, type 2 diabetes, and body weight control has been investigated in extensive studies but whole grains intake is still below the recommended amounts around the world (EUFIC, 2015).
The aim of this study is to determine the whole grain consumption of adults and their attitudes and thoughts about whole grain.
2. GENERAL INFORMATION
2.1. DEFINITION OF WHOLE GRAINS
Whole grains are a group of cereal foods that have an intact grain (Marshall et al., 2020). Kernels of cereal grain consist of three main components: endosperm, bran, and germ (Kamp et al., 2014). There are viscous soluble fibers, fermentable oligosaccharides, resistant starch (RS), lignans, vitamins, minerals, polyphenols, oils, and other phytonutrients in the inner germ and starchy endosperm. The outer bran layer consists of nondigestible carbohydrates such as cellulose, hemicelluloses, arabinoxylan, mostly insoluble, poorly fermentable (Jonnalagadda et al., 2011)(Slavin et al., 2013).
Figure 2.1. The primary parts of Whole-wheat grain (Călinoiu & Vodnar, 2018).
There are differences between refined grains and whole grains. They differentiate by milling, pearling, polishing, or de-germing any or all of the outer bran layers (Julie Miller Jones et al., 2020). During the processing of whole grains into white flour, the outer bran and inner germ layers are removed and the residual endosperm is processed into flour. There are also major losses of essential minerals, vitamins, and phytonutrients as a result of the refining process (Jonnalagadda et al., 2011)(Slavin et al., 2013). These processes also reduce dietary fiber by about 75 percent and some of the antinutritional components contained in the bran(Julie Miller Jones et al., 2020). Thus, whole grains are naturally richer in dietary fiber compared to refined grains, producing approximately 80% more dietary fiber than refined grains (Jonnalagadda et al., 2011)(Slavin et al., 2013). The original grains undergo processing and reconstitution must have the same proportion of bran, germ and endosperm to be considered as whole grains (Jonnalagadda et al., 2011). A variety of definitions accept that whole grain products should contain over half their weight from whole grain sources (Seal & Brownlee, 2015).
According to the Cereals and Grains Association whole grains consist of the intact, ground, cracked, flaked or otherwise processed kernel after the elimination of indigestible components such as the hull and husk (Nirmala Prasadi & Joye, 2020). A similar definition is also done by The U.S. Food and Drug Administration (FDA) and American Association of Cereal Chemists (AACC) International as those whole grains are intact, ground, cracked or flaked fruit of the grain which has principal components. The starchy endosperm, germ and bran, are present in the same relative proportions as they exist in the intact grain (Cooper et al., 2015)(Jonnalagadda et al., 2011). This description also makes it possible to minimize the loss of these three components throughout the course of the processing of whole grains (Seal & Brownlee, 2015). Small component losses under 2% of the germ or 10% of the bran, which can occur through safety and quality-consistent processing methods, are acceptable (Cooper et al., 2015). In order to be classified as a whole grain food by the International Cross-Disciplinary Group, at least 8 grams of each 30 gram of the product should be composed of whole grain (Seal & Brownlee, 2015).
Dietary guidelines currently provide suggestions for eating whole grains in many countries around the world (Mathews & Chu, 2020). Whole grain consumption of men and women around the world is showed below (figure 2.2. and figure 2.3.).
Figure 2.2.Whole grain intake of men in the world, 2010 (g/day) (GDD, 2015)
Figure 2.3. Whole grain intake of women in the world, 2010 (g/day) (GDD, 2015)
World Health Organization affirms whole grains as an essential part of balanced diet (WHO, 2021). However, whole grains intake is below the recommended amounts around the world (EUFIC, 2015). For example, more than 70 percent of people consume less than dietary guidelines and less than 2 servings (32 g of whole grains) of grains in the United Kingdom. In fact, 18% of adults and 15% of children / young people never consume grains (Mann et al., 2015). Moreover, 2011-2015 Danish national survey in Denmark recorded an average intake of 55 g for whole grains considerably lower than the recommended amount which is 75 g per day (Mathews & Chu, 2020).
Also, in a study published in France in 2014, 55 percent of children and 68 percent of adults never eat whole grains, half of participants consume whole grains <10 g / day (Bellisle et al., 2014). Additionally, in a study conducted in Germany, 19% of children and adolescents do not consume whole grains and the general intake was 20-33 g / day which is around half of the recommendations (Alexy et al., 2010). Also, according to Turkey Nutrition and Health Survey (TBSA), the percentage of those who never consume whole grain bread is 71.4 percent in Turkey (TBSA, 2014).
The Swedish National Food Agency recommends a daily intake of approximately 70 g and 90 g of whole grain for women and men respectively (Nirmala Prasadi & Joye, 2020) while the 2015-2020 Dietary Guidelines for Americans suggest a minimum equivalent 48 g of whole grains should be consumed per day in the United States. However, the National Health and Nutrition Survey (NHANES) for 2009-2010 showed average intakes of less than one third of the recommended amounts for all age groups in the US population (Mathews & Chu, 2020).
Although the recommendations differ from the general guidance on enhancing whole grains, the statistical guidelines identify a daily target amount to highlight the significance of eating whole grains for health maintenance (Mathews & Chu, 2020). Furthermore, the International Whole Grain Day emphasizes the importance of whole grain consumption and wellness, well-being and sustainability for healthier lives in the world per year on 19 November (George, 2020).
2.2. CONSUMER’S ATTITUDES TO WHOLE GRAINS
Whole Grains Council has been recorded the number of whole grain foods and a change to whole grain offerings increase in all categories (J. M. Jones & Sheats, 2015). Whole grain foods are often recognized by the use of food labeling and by their appearance and color. Consumers may become confused while choosing refined grains instead of whole grain sources by mistake without sufficient knowledge of how to read a label and classify whole grains. This inadvertently reduces whole grain consumption (Foster et al., 2020). In particular, there are variations in descriptions of what leads to the consumption of whole grain and what forms a whole grain food (Kissock et al., 2020). Due to the lack of consistency in the methods used to measure intakes, it is difficult to make comparisons between populations, to assess how whole grains exert their protective impact, the amounts needed to sustain better health and to evaluate the effectiveness of health promotion strategies (A. R. Jones et al., 2017).
Research indicates that low consumption of whole grains can be due to limited knowledge of whole grain foods, lack of link between whole grain and possible health benefits, unfavorable taste, limited time and knowledge for the preparation of whole grain foods (MacNab et al., 2017). Therefore, potential barriers to adequate whole grain consumption relate to taste, lack of knowledge of health benefits, family effects, price and availability of whole grains. Current research study shows that education, cost and taste were common factors identified by participants to help them select whole grain foods more frequently (Foster et al., 2020).
Singapore’s current strategies for public health are aimed at raising the regular consumption of whole grain foods, especially by offering out-of-home whole grain alternatives and using a symbol of healthier choice for food items. (Neo & Brownlee, 2017). Moreover, E.M. Barrett, et al. emphasize that awareness of consumer preferences and attitudes towards added-fiber grain foods relative to whole-grain foods, including current knowledge of whole grain and fiber benefits, is necessary to consider the utility of such items as a tool for enhancing the health value of grain choices (Barrett et al., 2020).
2.3. DIET AND WHOLE GRAINS
Cereal grains are one of the main food sources contributing up to 300 million tons a year in the world (Călinoiu & Vodnar, 2018). Worldwide, health promotion institutions accept the essential role of grain-based foods in their guidelines based on food groups. Since 2005, dietary guidance has emphasized the significance of whole grain foods by clearly mentioning that half of the grains should be whole grains (Julie Miller Jones et al., 2020). The Mediterranean Diet Pyramid also recommends that for each main meal 1-2 servings of cereal, particularly whole grain should be consumed (Ruggiero et al., 2019). However, a recent study analyzing consumption across 195 countries found that about 3 million deaths could be attributed to insufficient intake of whole grain in 2017, accounting for just 27 percent of the 11 million deaths attributed to any dietary risk factor (Barrett et al., 2020).
Due to their fractions, bran and germ, which contain specific health-promoting bioactive components, whole grains possess great nutritional and bioactive properties. In human intervention research, as well as a 2012-2016 World Health Organization survey, the evidence of health benefits supports the dietary intake of whole grains and whole-grain foods (Călinoiu & Vodnar, 2018).
2.3.1. THE NUTRITIONAL COMPOSITION OF WHOLE GRAINS AND THEIR HEALTH BENEFITS
The bran is the multi-layered outer skin that helps protect the other two components of the kernel from sunlight, pests, and water. Fiber, minerals such as iron, zinc, copper and magnesium, vitamin E, B group vitamins are found in the bran. Also, bran part has a variety of bioactive compounds such as flavonoids and carotenoids which have a beneficial biological impact on the body. New evidence indicates that they may be responsible for many of the health benefits of whole grains along with fiber. Additionally, the germ which is also known as embryo consist of essential unsaturated fats, B vitamins, selenium, vitamin E, antioxidants, plant sterols, and other compounds that are bioactive. Lastly, the largest part of the kernel is the endosperm, which primarily includes starchy carbohydrates, some proteins, and small quantities of fiber, vitamins, and minerals (EUFIC, 2015).
2.3.1.1. DIETARY FIBER
Dietary fiber was consumed as part of the carbohydrate fraction within food for millennia (Fuller et al., 2016). It has two types; soluble and insoluble fiber. Soluble fibers absorb water, which contributes to the formation of gel, which increases the transit time of food, delays gastric emptying, reduces the absorption of nutrients and slows digestion. Vegetables such as carrots, broccoli, onion, and artichokes and fruits such as bananas, berries, apples, and pears, as well as legumes, oats, and barley are food sources of soluble fiber. Besides insoluble fiber reduces transit time and increases fecal bulk and prevent constipation. Whole grain, wheat, bran, nuts, and seeds, as well as in some fruits and vegetables rich in insoluble fibers (Soliman, 2019).
Higher dietary fiber intake has inverse correlation between premature mortality, noncommunicable diseases and their risk factors in the general population (Reynolds et al., 2020).
2.3.1.2. CAROTENOIDS
Carotenoids are a category of pigments that are only synthesized by plants and microorganisms. Carotenoids have strong antioxidant properties and they are responsible for the red, yellow, and orange colors in fruits, vegetables, and whole grains. There are more than 600 carotenoids in nature and common types of carotenoids in whole grains include α and β-carotene, β-kryptoxanthin, zeaxanthin and lutein. Many biological processes have been linked to carotenoids including the prevention of chronic diseases, cardiovascular diseases and multiple cancers (Borneo & León, 2012).
2.3.1.3 PHENOLIC ACIDS
Phenolics are components that have one or more aromatic rings with one or more hydroxyl groups. Phenols, phenolic acids, and flavonoids are all phenolics. Common phenolic acids found in whole grains are ferulic acid which can be found in free, soluble or insoluble form such as corn, wheat, oats, rye. The health benefits of phenolic acids are generally associated with their antioxidant activity (Borneo & León, 2012). Phenolic acids are important to human health because they are potential antioxidants that prevent cell damage caused by free-radical oxidation processes. They are easily absorbed through intestinal tract walls. Humans' anti-inflammation capacity is also enhanced by phenolic acids when consumed on a regular basis (Kumar & Goel, 2019).
2.3.1.4. VITAMINS AND MINERALS
A variety of B vitamins such as thiamin, riboflavin, niacin and folate and minerals such as iron, magnesium and selenium are essential composition of whole grains. B vitamins play a key role in metabolism and it is essential for healthy nervous system. Also, they support the body in releasing energy from protein, fat and carbohydrate. Moreover, folate helps the body form red blood cells which reduces the risk of neural tube defects and spina bifida during fetal development. In addition, Whole grains are source of magnesium and selenium. Magnesium is a mineral used in building bones and releasing energy from muscle. Selenium protects cells from oxidation. It is also important for a healthy immune system. Moreover, whole grain products are major source of non-heme iron which is used to carry oxygen in the blood (USDA, 2020).
2.4. RELATIONSHIP OF WHOLE GRAINS WITH DISEASES AND PUBLIC HEALTH
Current epidemiological studies indicate that the intake of whole grain components appears to be associated with a lower risk of different chronic lifestyle-related diseases especially type 2 diabetes, obesity, and cardiovascular diseases, hypertension, gastrointestinal cancer and mortality (Marshall et al., 2020) (Jawhara et al., 2019) (Călinoiu & Vodnar, 2018)(Kirwan et al., 2016). Additionally, some studies show that whole grains can reduce blood pressure, cholesterol and fasting glucose (Kirwan et al., 2016). Whole grain intake is also linked to improved health and treatment outcomes in some inflammation related chronic diseases and contributes to human-microbe symbiosis (Jawhara et al., 2019).
2.4.1. OBESITY
Overweight and obesity are international health concerns that keep rising (Kirwan et al., 2016). In 2016, The World Health Organization stated that 1.9 billion people are overweight and 650 million are obese. Current studies showed that there is an adverse association between whole grain intake and risk of obesity (Kikuchi et al., 2018)(Choumenkovitch et al., 2013)(Ye et al., 2012). According to the World Health Organization report, whole grain consumption may reduce the risk of obesity (WHO, 2018). Also, systematic reviews and meta-analyses affirm positive correlations of whole grain consumption and body weight measures in observational and randomized control studies (Harland & Garton, 2008) (Pol et al., 2013)(Maki et al., 2019). Additionally, there are positive effects of whole grain consumption on body weight, BMI, percentage of body fat and waist circumference (Kissock et al., 2020b).
There are a variety of mechanisms that may help to weight control through the consumption of whole grains. One of these mechanisms is that the higher non-digestible carbohydrate content of whole grain product has a lower energy density (kilocalories/unit weight) (Călinoiu & Vodnar, 2018).
A whole grain enriched diet can lead to a greater difference in body composition (Kirwan et al., 2016) because it increases satiety and the feeling of fullness via dietary fiber (Călinoiu & Vodnar, 2018). Cross-sectional and long term prospective epidemiological studies show that the consumption of whole grains and whole grain products is related to decrease the risk of obesity and weight gain (Jonnalagadda et al., 2011) (Călinoiu & Vodnar, 2018).
Călinoiu and his friends showed in their study that, three servings of whole grain (48 g) per day may contribute to a lower body mass index, smaller waist circumference and lower body fat levels (Călinoiu & Vodnar, 2018).
2.4.2. TYPE 2 DIABETES
Diabetes is a chronic disease where the human body loses the capability to generate or use insulin effectively. Type 2 diabetes is a metabolic disorder caused by inadequate pancreatic insulin production (Nirmala Prasadi & Joye, 2020). It is a disease that impacts a rising percentage of the world's population (Jonnalagadda et al., 2011). The International Diabetes Foundation has estimated that 463 million people have diabetes globally in 2019 and it will increase about 51% in the world by 2045 (Atlas, 2019). Besides, according to the World Health Organization, deaths from diabetes increased by 70% globally between 2000 and 2019 (WHO, 2021).
Several studies emphasized that type 2 diabetes risk decreases with high consumption of whole grain (McRae, 2017). Randomized controlled trials demonstrated that whole grain intake improves blood glucose regulation and insulin sensitivity. Also, it decreases fasting insulin level and insulin resistance (Călinoiu & Vodnar, 2018).
Whole grain products that naturally have a higher content of dietary fiber. It is an essential ingredient and is considered to be at least partly responsible for these health benefits. A variety of human studies have shown an inverse association between cereal fiber consumption and the risk of type 2 diabetes. Increasing the daily consumption of fiber by 15g or up to 35g is predicted to reduce the risk of premature mortality in adults with diabetes (Reynolds et al., 2020). Furthermore, a cohort study which evaluated the risk of type 2 diabetes and different cereals and whole grain products consumption such as rye bread, whole grain bread and oatmeal/muesli found that people who consume 16 g of whole grain serving per day, have 11 percent and 7 percent lower type 2 diabetes risk for men and women respectively (Călinoiu & Vodnar, 2018).
2.4.3. HYPERTENSION
Hypertension has become a major public health problem and causes death which has increased by 56.1% in the world (Kashino et al., 2020) and around one-third of the adult population worldwide has arterial hypertension (Valenzuela et al., 2020). There are indeed modifiable risk factors associated with hypertension such as unhealthy diets, physical inactivity, alcohol and tobacco use (Kashino et al., 2020). It is also a common comorbidity of obesity, which is a significant cardiovascular disease risk factor (Kirwan et al., 2016).
Heart-healthy diets such as the Dietary Approaches to Stop Hypertension (DASH) or the Mediterranean diet pattern are recommended for the prevention of hypertension (Byun et al., 2019). Both of these diets include whole grains (Fung et al., 2010), which has several kinds of nutrients such as fiber, vitamins and minerals (Kashino et al., 2020). These components reduce hypertension risk (Borneo & León, 2012).
A meta-analysis of four cohort studies done in the U.S. suggested that the risk of hypertension was inversely correlated with whole grain consumption (Kashino et al., 2020). The French NutriNet-Santé cohort recently reported that 15 percent lower hypertension risk odds for people who consume whole grains (Byun et al., 2019). In addition, the anti-inflammatory effects of whole grains can also lead to lower blood pressure and the risk of cardiovascular diseases (Jonnalagadda et al., 2011).
In the Health Professionals' Report, people consuming at least 4 daily servings of whole grains per day have a 23 percent lower risk of hypertension (Byun et al., 2019).
2.4.4. CARDIOVASCULAR DISEASE
Cardiovascular disease (CVD) is a class of conditions that affect the heart or blood vessel structures or function. A combination of risk factors, such as tobacco use, unhealthy diet, obesity, lack of physical activity, excessive alcohol consumption, hypertension, diabetes and hyperlipidemia are typically the cause of heart attacks and strokes. It is one of the leading causes of death in the world (George, 2020). The World Health Organization estimated that 17.7 million people died from cardiovascular diseases in 2015 (WHO, 2018). Same organization also reported that cardiovascular disease will cause nearly 23.3 million deaths each year by 2030 (George, 2020).
Whole grain foods are recommended because of their cardioprotective properties, including dietary fibers, trace minerals and antioxidants (Wang et al., 2020). The aleurone-rich products due to their bioactive contents when they consumed regularly, it may considerably decrease plasma concentrations of the inflammatory marker, C-reactive protein which is significant risk factor for cardiovascular disease. Also, Whole grains are rich in phytochemicals that compete for absorption of cholesterol in the small intestine, reducing LDL cholesterol, a triggering factor for CVD (Călinoiu & Vodnar, 2018). The high intake of whole grain and bran mixtures had a greater positive effect on minimizing the risk of CVD death, CVD events, and heart failure (Călinoiu & Vodnar, 2018).
The most recent meta-analyses demonstrated that there is a strong inverse relationship between dietary whole grain intake and the occurrence of cardiovascular diseases (Călinoiu & Vodnar, 2018). Observational studies have reported intake of whole grain foods is associated with lower metabolic syndrome occurrence and lower CVD mortality rates (Wang et al., 2020). Framingham Offspring report also highlighted that whole-grain diets were inversely correlated with total cholesterol, low-density lipoprotein (LDL), cholesterol and body mass index (George, 2020).
George E. showed in his study that, people who consume 90 g of whole grains which is 3 servings, there is a substantial reduction in the risk of cardiovascular disease, stroke, and coronary heart disease (George, 2020). The Australian dietary guidelines clarified that grain foods which is primarily whole grains are recommended for adults at least 4 to 6 times a day, especially for people who is at high risk of cardiovascular diseases (Wang et al., 2020).
3. METHODOLOGY
3.1. THE PLACE AND TIME OF STUDY
This study was done in Aydın, Turkey between February 2021 and March 2021 dates.
3.2. POPULATION OF STUDY
This study was done on 19-65 years old 50 adults in Aydın who don’t have any physical or psychologic problem. All the participants voluntarily attended to the study and they gave written informed consent.
3.3. DATA COLLECTION
All questionnaires were done face to face individually. Although the duration of the questionnaires varies between individuals, grain knowledge and awareness level part about 7 minutes, whole grain consumption frequency and amount part of it took approximately 13 minutes and 20 minutes in total.
The questionnaire consists of 4 parts including demographic characteristics, anthropometric measurements, knowledge and attitude to whole grains and food frequency questionnaire.
3.3.1. GENERAL INFORMATION COLLECTION
In this part of the questionnaire, 11 questions were asked to participants which include demographic characteristics such as gender, age, marital status, occupation, income status, living place and other information like disorders, physical activity, alcohol consumption and smoking.
Anthropometric measurements include weight and height, BMI, waist and hip circumference, waist to hip ratio and waist to height ratio and they were measured for each participant. Participants were weighed with light clothes and without cardigans, coats, belts and shoes. Their pockets were emptied and jewelry was removed. Measurements were performed on an empty stomach and after urinate or defecation. Participants were not hold onto the anything to support and they were stand on both feet equally. Height measurement was taken by tape. Participants were on flat ground and against a flat surface such as a wall, stood Frankfurt plane with feet flat together. Also, legs were straight, arms were sides and shoulder were level against to the wall. They touched the wall with head, shoulders, buttocks and heels. BMI is a measure for signal of nutritional status in adults. It is defined as a person’s weight in kilograms divided by the square of the person’s height in meters (kg/m2). BMI is calculated by the researcher and evaluated according to the WHO classification.
Table 3.1 BMI Classification (WHO, 2020)
BMI
Nutritional Status
Below 18.5 kg/m2
Underweight
18.5-24.9 kg/m2
Normal weight
25.0-29.9 kg/m2
Pre-obesity
30.0-34.9 kg/m2
Obesity class I
35.0-39.9 kg/m2
Obesity class II
Above 40.0 kg/m2
Obesity class III
Waist Circumference is measured by tape. Participants stood and place a tape measured around middle, just above the hipbones. Tape was horizontal around the waist and it was not tight. The measurement was taken after the participants breath out.
Hip circumference is measured also by tape. Participants stood and place a tape measured around widest part of the hip. Tape was horizontal around the waist and it was not tight.
Waist to hip ratio is the dimensionless ratio of the circumference of the waist to that of the hips. It is as an indicator for risk of developing serious health conditions. This is calculated as waist measurement divided by hip measurement (W/H) and evaluated according to the WHO classification by the researcher.
Table 3.2. Waist to Hip Ratio Chart (WHO, 2020)
Health risk
Women
Men
Low
0.80 or lower
0.95 or lower
Moderate
0.81–0.85
0.96–1.0
High
0.86 or higher
1.0 or higher
Waist to height ratio which is a measure of the distribution of body weight is defined as waist circumference divided by height and both measured in the same units and evaluated according to the Ashwell classification.
Table 3.3. Waist to Height Ratio Chart (TÜBER, 2016).
Waist/Height
Classification
<0.4
Risky
0.4<0.5
Normal
0.5<0.6
Risky
>0.6
Needs Treatment
3.3.2. WHOLE GRAIN KNOWLEDGE
In this part of the questionnaire, the level of knowledge about whole grain and whole grain products are aimed to be evaluated. There are 3 questions about whole grain knowledge and the daily recommendation for consumption.
Among these questions, it was asked if the expression whole grain has been heard before and evaluated with the answers of the participants "yes", "no" and "do not know". Also, ‘’grain statement’’, ‘’color of the food’’, ‘’cereal’’, 100% whole wheat, whole grain or multi-grain’’ information on the product packaging were asked if indicate either the food is whole grain or not by ‘’ yes’’ ‘’no’’ and ‘’I don't know’’ answers to evaluate the information. In addition, whether various foods such as white bread, wheat bread, whole wheat bread, multigrain bread, rye bread, whole grain pasta and popcorn are whole grain answered by ‘’100% whole grain, not a whole grain and I do not know / not sure’’ answers. Lastly, questions were asked about the recommended daily portion of whole grain.
3.3.3. ATTITUDES TO WHOLE GRAINS
In this part of the questionnaire, both whole grain products and refined grain products were designed to determine the participant’s product preferences. Also, they were asked about digestion and health benefits of whole grains, taste, price, naturalness, satiety and nutritiousness. Moreover, they were asked to evaluate their thoughts on whether whole grains are useful for various diseases such as hypertension, type 2 diabetes, obesity, bowel diseases (constipation, diverticulum), heart disease and cancer with "yes", "no" or "I don't know" answers.
3.3.4. FOOD FREQUENCY QUESSTIONNAIRE SPECIFIED FOR GRAINS
In the third stage of the questionnaire, the grain consumption was asked. Questionnaire includes 23 items such as white flour, whole grain flour, whole grain / whole wheat bread and types, whole rye bread, types of white bread, multigrain bread, rice, brown rice, cracked wheat, buckwheat, pasta, whole cereal pasta / noodles / noodles, quinoa/chia/amaranth/flaxseed, oatmeal, muesli, granola/granola bar, whole grain breakfast cereal, popcorn and corn chips, crackers/biscuits/cake, whole grain crackers / biscuits/cake.
The frequency of consumption is evaluated by every meal, every day, once or twice a week, 2-3 times a week, 3-4 times a week, 5-6 times a week, once a two week, once a month and never answers.
In line with the measurements given in the second part, where the consumption of cereal foods is evaluated, the question how much they were asked to indicate the amount they consumed.
Daily grain consumption of individuals was analyzed with a computer aided program developed for Turkey called ‘Nutrition Package Information Systems Program (BEBİS).
3.4. DATA ANALYSIS
In this research, the knowledge and attitude of whole grain and its relationship with consumption among adults who lives in Aydın, Turkey has been evaluated. The data obtained was analyzed with appropriate statistical techniques within the scope of the study with Statistical Package for Social Sciences (SPSS) program.
4. RESULTS
Tablo 4.1. Distribution of general information about consumers
Frequency
%
Gender
Male
18
36,0
Female
32
64,0
Marital Status
Married
18
36,0
Single
32
64,0
Occupation
Civil Servant
9
18,0
Private Sector
26
52,0
Not Working
7
14,0
Student
7
14,0
Retired
1
2,0
Income Status
Less than income
6
12,0
Income equal to expenses
21
42,0
More than income
23
46,0
Table 4.1. illustrates that participants’ general information. There were 50 participants and 36,0% of them were male and 64,0% of them were female. Also, 36,0% of participants were married while 64,0% of them were single. Moreover, 52,0% of participants were working in private sector and 18% of them were working in civil servant. On the other hand, 14,0% of participants were student and not working, 2,0% of them were retired. However, 46,0% of participants had more income than expenses while 42,0% of them had income equal to expenses and rest of them which is 12,0% had less than income.
Table 4.2. Distribution of consumers according to lifestyle habits and health status
Frequency
%
Living place
With family
41
82,0
With friends
1
2,0
Alone
8
16,0
Health problem
No
41
82,0
Yes
9
18,0
Exercise
No
37
74,0
Yes
13
26,0
Alcohol
No
25
50,0
Yes
25
50,0
Smoking
No
30
60,0
I smoked and gave up
4
8,0
Yes, still smoking
16
32,0
Table 4.2. is about participants’ lifestyle habits and health status. 82,0% and 2,0% of participants were living with their family and friends respectively while 16,0% of them alone. Also, 82,0% of them didn’t have any health problem but rest of them which is 18,0% had. On the other hand, 74,0% of participants were doing exercise while 26,0% were not. Half of the participants were consuming alcohol while the other half were not consuming. Furthermore, 60,0% of participants were smoking while 32,0% were smoking and 8% of them had smoked and gave up.
Table 4.3. Distribution of age according to gender
n
min-max
x±sd
Gender
Male
18
20-61
34,38±13,07
Female
32
19-54
30,75±9,08
Table 4.3. indicates that distribution of age according to gender. 50 of 18 participants were male and rest of 32 are female. Moreover, the younger and older age was 20 and 61 for male, 19 and 54 for female. The average age was 34,38±13,07 for male and 30,75±9,08 for female.
Table 4.4. Distribution of consumer’s anthropometric measurements according to gender
Anthropometric Measurements
Male (18)
Female (32)
x±sd
min-max
x±sd
min-max
Weight
83,19±22,24
62,3-150,5
63,15±11,56
45,2-89,4
Height
177,00±7,01
165,0-189,0
163,25±6,18
150,0-177,0
BMI
26,29±5,75
19,0-44,9
23,16±3,94
16,0-30,8
Waist circumference
96,77±16,65
75,0-139,0
77,90±11,99
61,0-105,0
Hip circumference
102,88±11,96
85,0-136,0
96,21±11,41
65,0-121,0
Waist to hip ratio
,91±,11
,7-1,2
,76±,06
,7-,9
Waist to height ratio
,52±,10
,4-,7
,43±07
,3-,6
Table 4.4. emphasizes that participants’ anthropometric measurements according gender. The lowest weight was 45,2 kg and height was 150,0 cm for female and the highest weight was 150,5 kg and height was 189,0 cm for male. Further, the average BMI for male and female were 26,29±5,75 and 23,16±3,94 respectively. Also, the average waist circumference for male and female were 96,77±16,65 cm and 77,90±11,99 cm respectively. Moreover, the average hip circumference for male was 102,88±11,96 cm and for female was 96,21±11,41 cm. Furthermore, waist to hip ratio and waist to height ratio for male was ,91±,11 and ,52±,10 while for female was ,76±,06 and ,43±07 respectively.
Table 4.5. Distribution of consumer’s knowledge about whole grain according to BMI
Knowledge about whole grains
BMI
≤24.99
≥25.00
Total
n
%
n
%
n
%
Term of whole grain
No
Yes
0
32
,0
100,0
0
18
,0
100,0
0
50
,0
100,0
Definition of whole grain
Brown and natural
Consist of bran germ and endosperm
Consist of brown and extracted grain
9
20
3
28,1
62,5
9,4
3
12
3
16,7
66,7
16,7
12
32
6
24,0
64,0
12,0
Table 4.5. Distribution of consumer’s knowledge about whole grain according to BMI (continued)
Knowledge about whole grains
BMI
≤24.99
≥25.00
Total
n
%
n
%
n
%
Description of whole grain
Brown in color
Named as grain
Named as 100% whole wheat
0
1
31
,0
3,1
96,9
0
2
16
,0
11,1
88,9
0
3
47
,0
6,0
94,0
Table 4.5. demonstrates that participants’ knowledge about whole grains according to BMI. All the participants (100%) who had normal BMI or overweight heard about term of whole grain. However, 66,7% of overweight or obese participants knew whole grain definition more than the participants who had normal BMI (62,5%). Moreover, 28,1% of participants with normal weight and 16,7% of overweight-obese participants thought whole grains means as brown and natural. Nevertheless, 16,7% of overweight participants thought whole grain as brown and extracted which is higher than participants who had healthy weight (9,4%). Besides, 94% of total participants descripted whole grain as named 100% whole wheat while 6% of them named as only grain. Moreover, 96,9% of participants with normal weight and 88,9% of participants with overweight or obese named whole grain as 100% whole wheat.
Table 4.6. Distribution of recognizing whole grain products according to BMI
Whole grain products
BMI
≤24.99
≥25.00
Total
n
%
n
%
n
%
White bread
100% whole wheat
Not whole grain
I don’t know
3
26
3
9,4
81,3
9,4
1
16
1
5,6
88,9
5,6
4
42
4
8,0
84,0
8,0
Table 4.6. Distribution of recognizing whole grain products according to BMI (contunied)
Whole grain products
BMI
≤24.99
≥25.00
Total
n
%
n
%
n
%
Wheat bread
100% whole wheat
Not whole grain
I don’t know
15
15
2
4,9
46,9
6,3
5
9
4
27,8
50,0
22,2
20
24
6
40,0
48,0
12,0
Whole grain bread
100% whole wheat
Not whole grain
I don’t know
28
2
2
87,5
6,3
6,3
16
2
0
88,9
11,1
,0
44
4
2
88,0
8,0
4,0
Multi-grain bread
100% whole wheat
Not whole grain
I don’t know
22
9
1
68,8
28,1
3,1
11
4
3
61,1
22,2
16,7
33
13
4
66,0
26,0
8,0
Rye bread
100% whole wheat
Not whole grain
I don’t know
19
10
3
59,4
31,3
9,4
6
11
1
33,3
61,1
5,6
25
21
4
50,0
42,0
8,0
Brown rice
100% whole wheat
Not whole grain
I don’t know
15
9
8
46,9
28,1
25,0
3
7
8
16,7
38,9
27,8
18
16
16
36,0
32,0
32,0
Whole wheat pasta
100% whole wheat
Not whole grain
I don’t know
10
15
7
31,3
46,9
21,9
7
6
5
38,9
33,3
27,8
17
21
12
34,0
42,0
24,0
Popcorn
100% whole wheat
Not whole grain
I don’t know
1
25
6
3,1
78,1
18,8
2
12
4
11,1
66,7
22,2
3
37
10
6,0
74,0
20,0
Table 4.6. shows participants’ awareness about whole grain products according to BMI. 84,0% of total participants knew that white bread is not whole grain and 88,0% of them aware about that whole grain is 100% whole wheat. Moreover, 88,9% of overweight participants and 81,3% of healthy participants described white bread as not whole grain. Addition to this, 88,9% of participants with overweight and 87,5% of participants with normal weight described whole grain bread as 100% whole wheat. Furthermore, 46,9% of participants with healthy weight and half of the overweight participants described wheat bread as not whole grain. On the other hand, 28,1% of healthy participants and 22,2% of overweight participants described multi-grain bread as not whole grain. Also, 31,3 % of participants with normal weight and 61,1 % of participants with overweight described rye bread as not whole grain. Moreover, 31,3 % of healthy participants and 38,9% of overweight participants described whole wheat pasta as whole grain. Furthermore, 78,1% of participants with normal weight and 66,7 of overweight participants described popcorn as not whole grain. Lastly, 46,9% of healthy participants and 16,7% of overweight participants described brown rice as 100% whole wheat.
Table 4.7. Consumer’s knowledge about recommended portion of whole grain consumption according to BMI
Recommended whole grain consumption
BMI
≤24.99
≥25.00
Total
n
%
n
%
n
%
Known
Unknown
30
2
93,8
6,3
17
1
94,4
5,6
3
47
94,0
6,0
Table 4.7. emphasizes that participants’ knowledge about recommended portion of whole grain consumption according to BMI. 6,0% of total participants didn’t know about recommended portion of whole grain consumption. Overweight participants (94,4%) knew recommended portion of whole grain consumption more than healthy participants (93,8%).
Table 4.8. Distribution of consumer’s thoughts about the properties of whole grains according to BMI
Properties of whole grains
Consumer’s thoughts
BMI
≤24.99
≥25.00
Total
n
%
n
%
n
%
Like the taste of whole grain
No
Yes
I don’t know
6
25
1
18,8
78,1
3,1
1
17
0
5,6
94,4
,0
7
42
1
14,0
84,0
2,0
Prefer the taste of whole grain
No
Yes
I don’t know
23
9
0
71,9
28,1
,0
16
2
0
88,9
11,1
,0
39
11
0
78,0
22,0
,0
Prefer whole flour
No
Yes
I don’t know
14
18
0
43,8
56,3
,0
10
7
1
55,6
38,9
5,6
24
25
1
48,0
50,0
2,0
Whole grain expensiveness
No
Yes
I don’t know
7
23
2
21,9
71,9
6,3
5
9
4
27,8
50,0
22,2
12
32
6
24,0
64,0
12,0
Healthy
No
Yes
I don’t know
4
26
2
12,5
81,5
6,3
2
15
1
11,1
83,3
5,6
6
41
3
12,0
82,0
6,0
Decrease the risk of diseases
No
Yes
0
32
,0
100,0
2
16
11,1
88,9
2
48
4,0
96,0
Table 4.8. illustrates that participants’ thoughts about the properties of whole grains according to BMI. 84,0% of total participants like the taste of whole grain and 94,4% of these participants were overweight and 78,1% of these participants were normal weight. Moreover, %88,9 of overweight and 71,9% participants with normal weight didn’t prefer taste of whole grain bread compared to taste of white bread. Moreover, 56,3% of participants with normal weight and 38,9% of overweight participants preferred whole flour instead of white flour. Also, 64,0% of total participants thought that whole grain products are expensive. In addition to this, 71,9% of normal weight and half of overweight participants thought that whole grains were expensive. Most of the total participants (82,0%) thought that whole grain was healthy. On the other hand, 96,0% of the participants answered as whole grain reduces the risk of diseases. However, only 11,1% of overweight participants’ thought were opposite about reducing the risk of diseases.
Table 4.9. Comparison of daily grain consumption according to BMI
Grain Products
BMI/Daily Consumption
≤24,99 (32)
≥25,00 (18)
p
x±sd
min-max
x±sd
min-max
Whole wheat/whole grain bread
27,62±32,82
,0-150,0
26,03±32,50
,0-125,0
0,808
Whole rye bread
2,94±9,03
,0-50,0
2,68±4,54
,0-10,8
0,945
Different types of white bread
39,46±83,36
,0-450,0
46,74±106,50
,0-450,0
0,815
Multigrain bread
2,56±5,49
,0-21,7
3,24±6,83
,0-26,8
0,838
Whole grain or whole meal tortilla / lavash
6,37±23,27
,0-392
,00±,00
,0-,0
0,015
Whole grain or whole wheat hamburger bread / flatbread
1,84±5,55
,0-,0
,00±,00
,0-,0
0,053
Rice
38,84±71,50
,0-86,8
24,17±24,86
1,3-100,0
0,992
Cracked wheat
18,64±21,04
,0-100,0
23,59±28,03
1,0-100,0
0,670
Pasta
31,08±32,82
,0-100,0
22,84±18,05
2,0-43,0
0,707
Whole grain pasta / noodles
4,87±19,85
,0-86,8
11,11±37,81
,0-157,1
0,507
Quinoa / Chia / Amarant / Flaxseed
,53±1,15
,0-4,3
1,34±3,22
,0-10,0
0,920
Muesli
1,07±3,74
,0-15,1
1,91±5,31
,0-21,5
0,441
Oatmeal
4,78±12,60
,0-60,0
5,99±14,56
,0-60,0
1,00
Whole grain cereal
3,00±14,11
,0-80,0
,18±,77
,0-3,30
0,145
Cornflakes
2,93±14,10
,0-80,0
,94±2,37
,0-8,0
0,761
*50 participants in the survey didn’t consume any buckwheat and/or brown rice in past one month.
Table 4.9. Comparison of daily grain consumption according to BMI (continued)
Grain Products
BMI/Daily Consumption
≤24,99 (32)
≥25,00 (18)
p
x±sd
min-max
x±sd
min-max
Popcorn
1,88±5,65
,0-31,4
4,20±9,99
,0-31,4
0,144
Granola / granola bar
,16±,77
,0-4,3
,10±,44
,0-1,9
0,922
Crackers / biscuits / cake
24,07±27,80
,0-100,0
14,25±24,84
,0-100,0
0,115
Whole grain crackers / biscuits / cakes
4,68±10,54
,0-45,0
6,02±13,77
,0-50,0
0,607
*50 participants in the survey didn’t consume any buckwheat and/or brown rice in past one month.
Daily grain consumption was compared according to BMI in Table 4.9. Participants with normal BMI and overweight participants consumed whole grain bread 27,62±32,82 g and 26,03±32,50 g respectively. Also, different types of white bread consumption were 39,46±83,36 g for healthy participants and 46,74±106,50 g for overweight participants. While participants with normal weight were consuming whole grain tortilla 6,37±23,27 g and whole grain hamburger bread 1,84±5,55 g, overweight participants didn’t consume whole grain tortilla and/or hamburger bread. Moreover, rice consumption for participants who had normal weight and overweight were 38,84±71,50 g and 24,17±24,86 g respectively. Further, cracked wheat consumption were 18,64±21,04 g for participants with normal weight and 23,59±28,03 g for participants with overweight. Additionally, healthy participants were consumed 31,08±32,82 g pasta while overweight participants were consuming 22,84±18,05 g. On the other hand, popcorn consumption for participants with normal BMI and overweight were 1,88±5,65 g and 4,20±9,99 g respectively. Furthermore, participants with normal weight and overweight were consumed crackers/biscuits/cake 24,07±27,80 g and 14,25±24,84 g respectively. However, whole grain crackers/biscuits/cakes consumption for healthy participants were 4,68±10,54 g and for overweight participant were 6,02±13,77 g.
There wasn’t found any significant differences for whole grain bread, whole rye bread, whole grain hamburger bread, multi-grain bread, different types of white bread, rice, cracked wheat, pasta, whole grain pasta, quinoa/chia/amaranth/flaxseed, muesli, oatmeal, whole grain cereal, cornflakes, popcorn, granola/granola bar, crackers / biscuits / cake and whole grain crackers / biscuits / cake among the groups (p>0,05). The only significant difference found between the groups was for whole grain tortilla/lavash (p<0,05).
Table 4.10. Comparison of daily grain consumption according to gender
Grain Products
BMI/Daily Consumption
Man (18)
Woman (32)
p
x±sd
min-max
x±sd
min-max
Whole wheat/whole grain bread
19,57±30,46
,0-125,0
31,25±33,14
,0-150,0
0,084
Whole rye bread
4,76±11,8
,0-50,0
1,77±3,62
,0-10,8
0,314
Different types of white bread
87,59±140,1
,0-450,0
16,48±23,31
,0-75,0
0,023
Multigrain bread
,05±8,49
,0-26,8
1,22±2,81
,0-10,75
0,162
Whole grain or whole meal tortilla / lavash
9,96±30,74
,0-130,0
,76±2,63
,0-13,90
0,131
Whole grain or whole wheat hamburger bread / flatbread
3,10±7,22
,0-21,70
,10±,39
,0-1,60
0,073
Rice
70,49±86,47
6,70-392
12,79±13,93
,0-50,0
0,000
Cracked wheat
38,88±28,85
4,0-100,0
10,04±10,83
,0-43,0
0,000
Pasta
41,64±31,88
2,0-100,0
20,50±23,61
,0-100,0
0,006
Whole grain pasta / noodles
4,82±20,45
,0-86,8
6,43±28,52
,0-157,1
0,346
*50 participants in the survey didn’t consume any buckwheat and/or brown rice in past one month.
Table 4.10. Comparison of daily grain consumption according to gender (continued)
Grain Products
BMI/Daily Consumption
Man (18)
Woman (32)
p
x±sd
min-max
x±sd
min-max
Quinoa / Chia / Amarant / Flaxseed
,62±2,35
,0-10,0
,72±1,96
,0-10,0
0,375
Muesli
2,02±6,00
,0-21,5
1,01±3,09
,0-15,1
0,971
Oatmeal
1,77±5,18
,0-21,5
7,15±15,82
,0-60,0
0,104
Whole grain cereal
4,98±18,79
,0-80,0
,30±,83
,0-3,30
0,751
Cornflakes
4,62±18,82
,0-80,0
,86±1,97
,0-8,0
0,311
Popcorn
2,54±6,67
,0-28,0
2,81±8,02
,0-31,4
0,315
Granola / granola bar
,06±,25
,0-1,10
,19±,82
,0-4,3
0,883
Crackers / biscuits / cake
28,41±35,90
,0-100,0
16,10±19,59
,0-52,0
0,316
Whole grain crackers / biscuits / cakes
5,62±11,42
,0-45,0
4,90±12,01
,0-50,0
0,846
*50 participants in the survey didn’t consume any buckwheat and/or brown rice in past one month.
Daily grain consumption was compared according to gender in Table 4.10. Male participants and female participants consumed whole grain bread 19,57±30,46 g and 31,25±33,14 g respectively. Also, different types of white bread consumption were 87,59±140,1 g for male participants and 16,48±23,31 g for female participants. While male participants were consuming whole grain tortilla 9,96±30,74 g and whole grain hamburger bread 3,10±7,22 g, female participants consumed ,76±2,63 g whole grain tortilla and ,10±,39 g hamburger bread. Moreover, rice consumption for participants who are male and female were 70,49±86,47 g and 12,79±13,93 g respectively. Further, cracked wheat consumption were 38,88±28,85 g for male participants and 10,04±10,83 g for female participants. Additionally, male participants were consumed 41,64±31,88 g pasta while female participants were consuming 20,50±23,61 g. On the other hand, popcorn consumption for male and female participants were 2,54±6,67 g and 2,81±8,02 g respectively. Furthermore, male participants and female participants were consumed crackers/biscuits/cake 28,41±35,90 g and 16,10±19,59 g respectively. However, whole grain crackers/biscuits/cakes consumption for male participants were 5,62±11,42 g and for female participants were 4,90±12,01 g. There was strong significant difference between males and females for different types of white bread, rice, cracked wheat and pasta (p<0,05).
Table 4.11. Distribution of whole grain bread consumption who thought healthy and/or delicious according to BMI
Daily Whole Grain Bread Consumption (g)
≤24,99
≥25,00
n
x±sd
min-max
n
x±sd
min-max
p
Healthy
Yes
31
26,03±32,50
,0-150,0
18
26,09±32,19
,0-125,0
0,925
Delicious
Yes
21
25,35±23,40
,0-75,0
18
26,03±32,50
,0-125,0
0,666
Table 4.11. examines participants’ thoughts about whole grains and their consumption according to BMI. Participants who said healthy for whole grain bread, the consumption for normal weight and overweight participants were 26,03±32,50 g and 26,09≥±32,19 g respectively. Whereas, there was just the opposite between both group about taste of whole grain bread and consumption. Overweight participants who thoughts whole grain bread was delicious (26,03≥±32,50 g), consumed more than healthy weight participants (25,35±23,40 g). Nevertheless, difference between each group for both of the factors was not statistically significant (p>0,05).
5. DISCUSSION
The present study evaluates that adults’ whole grain consumption and their attitudes about whole grains in Aydın, Turkey.
5.1. SOCIODEMOGRAPHIC FEATURES
In this study, there were 36,0% of male and 64,0% of female participants (Table 4.1.). However, in another study which was done by Sari et al., there were 11,5% of male and 88,5% of female participants (Sari, 2018). Also, 60,0% of participants were smoking and 50% of participants were consuming alcohol in this current study (Table 4.2.). Nevertheless, 18,5% of participants were smoking and 15,0% of consuming alcohol in the other study (Sari, 2018). This study participants’ average age is higher than the study which was done in Acıbadem University. Therefore, percentage of smoking and consuming alcohol is higher in this study.
In this study, female’s body mass index (BMI) was lower than male’s body mass index (Table 4.4.). Also, male’s waist and hip circumference were higher than females as expected. On the other hand, males and females had low health risk according to the average waist to hip ratio. However, males were classified as risky while females were classified as normal for waist to height ratio.
5.2. KNOWLEDGE LEVEL OF WHOLE GRAINS
The present study illustrated that all participants (100%) knew definitions about whole grains (Table 4.5.). A similar study which was done in Turkey, Sari et al., found that 90.7% of participants heard about definitions related with whole grains (Sari, 2018). Moreover, another study which was done in USA, it was highlighted that, 100% of nutritionists, 98,0% of health club members and 86,0% of people who works in the nutrition program knew the whole grain expression (Marquart et al., 2006).
In a study done in Turkey, 81.2% of participants defined whole grains as containing the amount of bran, germ and endosperm found in natural cereal grain correctly (Sari, 2018). However, Table 4.5. showed that only 64,0% of participants defined whole grains correctly in this study.
The current study demonstrated that none of participants described whole grain products as brown color (Table 4.5.). Nevertheless, the study done by Marquart et al., examined that there were some participants who described products as whole grains according to their appearance and color (Marquart et al., 2006). On the other hand, another study highlighted that adults didn’t describe whole grains accurately (Burgess-Champoux et al., 2006) and also Chase et al., demonstrated that even dietitians were confused while determining whole grains (Chase et al., 2003) which were exact opposite in this study. Sari et al., support that with her study. She found that 79,9% of participants determined whole grain as accurately (Sari, 2018). Addition to this, 94,0% of this study participants named whole grains as "100% whole wheat, multi-grain or whole grain" which is correct answer (Table 4.5.).
The study which is done by Engleson et al., underlined that participants were confused about type of grains which are whole grain or not (Julie Miller Jones & Engleson, 2010). In this study participants who knows or not sure about popcorn (94,0%) as a whole grain was noticeably higher than other participants (38,3%) who belongs to a similar study (Sari, 2018). However, participants’ knowledge for other products which are rye bread (50,0%), whole wheat pasta (42%), brown rice (32,0%) and multi-grain bread (26,0%) were equal or less than 50% (Table 4.6.). Therefore, this study participants were also confused about these products. Moreover, a similar study demonstrated that consumers don’t know correct answer or don’t have any idea about knowledge of rye bread (26,2%), whole wheat pasta (31,3%), brown rice (39,3%) and multi-grain bread (24%). On the other hand, current study participants’ knowledge about white bread (84%) and whole grain bread (88%) were more than Acıbadem University participants’ knowledge for white bread (33,9%) and whole grain bread (50.5%) (Sari, 2018).
The 94,0% of participants’ knowledge about recommended whole grain consumption was 1-3 portion (Table 4.7.) which is supported by Turkey Nutrition Guide (TÜBER). According to TÜBER, people should consume at least half of the average consumption of 4-7 portions of cereal per day and this amount corresponds to at least 2 servings of whole grains (TÜBER, 2016). In a similar study participants’ knowledge about recommended consumption was only 28,8% (Sari, 2018) which is lower than our study. However, another study which is done by Marquart et al., underline that 45% of nutritionist and 41% of health club members answered recommended whole grains consumption as 5-11 servings and 6-12 servings a day respectively while their nutritionists were recommended more portions (Marquart et al., 2006).
5.3. ATTITUDE AGAINST WHOLE GRAINS
McMackin et al., highlighted in his study that consumption of whole grains depends on taste, texture, appearance and smell and the taste was distinguishing features while consuming whole grains (McMackin et al., 2013). Participants who had (85,0%) and didn’t have (95,0%) nutrition education indicated that they like the taste of whole grains. Also, in the same study, participants of who had and didn’t have nutrition education prefer the taste of white bread when compared with taste of whole grain bread by 67,0% and 64,0% respectively (Kantor et al., 2001). On the other hand, a similar study illustrated that 84,3% of participants like the taste of whole grains (Sari, 2018) which was similar with current study’s participants (84,0%) which was shown in Table 4.8. Also, Table 4.8. illustrated those 22,0% of participants preferred whole grain bread instead of white bread. On the other hand, 38% of participants preferred whole grain bread in a similar study (Sari, 2018). Additionally, in this study, 94,4% of overweight participants like the taste of whole grain bread but 88,9% of them don’t prefer to consume whole grain bread because of their daily habits.
The study done with 1569 participants were evaluated that terms of taste and price between whole grain and refined grain products and it was found that whole grain products were tasteless and cheaper than refined grains (Arvola et al., 2007). Addition to this, another study highlighted that 54,0% of student with nutrition education and 41,0% of student without nutrition education remarked that whole grain bread was not expensive than white bread (Williams & Patricia Mazier, 2013). However, in this study, it was found that 64,0% of participants indicated that whole bread was expensive than white bread (Table 4.8.). Because, markets in other countries might promote to sell whole grain products more than markets in our country. Moreover, a similar study demonstrated that 56,2% of participants had same thoughts as the current study. Furthermore, 12,0% of participants who participated current study don’t have any idea about expenses. However, 15,7% of Acıbadem University participants were not have any idea about expenses (Sari, 2018).
According to The International Food Information Council’s (IFIC) Nutrition and Health Survey (2017), 84,0% of participants were described whole grain as healthy (IFIC, 2019). In a similar study, 54,0% of participants thought that whole grains decrease the risk of diseases (Sari, 2018). However, 96,0% of current study participants thought that whole grains decrease the risk of diseases (Table 4.8.). On the other hand, Burgess et al., illustrated that participants who ate whole grains thought that whole grains less processed and healthier (Burgess-Champoux et al., 2006). Also, 82,0% of this study participants remarked that whole grains as healthy (Table 4.8.). Furthermore, in another study, participants indicated that they preferred whole grain products because of its health benefits (Kamar et al., 2016).
The current study participants’ thoughts for whole grain bread and their consumption were showed in Table 4.11. Participants who thought that whole grain bread is healthy, their consumption was 26,03±32,50 g for healthy weight and 26,09±32,19 g for overweight participants. On the other hand, participants who thought that whole grain bread is delicious, normal weight and overweight participants’ consumption were 25,35±23,40 g and 26,03±32,50 g respectively. However, Sari et al., found that participants who thoughts whole grain is healthy and delicious, they consumed whole grain bread as 133.6±143.4 g and 47.3±68.5 g respectively (Sari, 2018). Therefore, it was showed that this study participants were not consuming whole grain bread according to its health benefits.
5.4. GRAIN CONSUMPTION FREQUENCY
Table 4.9. illustrated that daily consumption of grains according to BMI. Participants with normal weight consumed 27,62±32,82 g whole grain bread which was more than overweight participants (26,03±32,50 g). However, different types of white bread consumed more by overweight participants (46,74±106,50 g) than healthy participants (39,46±83,36 g). Moreover, participants who had normal weight consumed 38,84±71,50 g rice more than overweight participants (24,17±24,86 g). Additionally, healthy participants were consumed 41,64±31,88 g pasta which was more than overweight participants (22,84±18,05 g). Nevertheless, cracked wheat consumption was lower in participants with normal weight 18,64±21,04 g than overweight participants (23,59±28,03). On the other hand, popcorn consumption lower in participants with normal weight (1,88±5,65 g) than overweight participants (4,20±9,99 g). Furthermore, while participants with normal weight consumed 24,07±27,80 g crackers/biscuits/cake which was more than participants with overweight (14,25±24,84 g); overweight participants consumed 6,02±13,77 g whole grain crackers/biscuits/cakes which was more than healthy participants (4,68±10,54 g). There isn’t any significant difference between the groups (p>0,05).
Daily consumption amounts of cereal products differ according to gender which was showed in Table 4.10. Current study demonstrated that male and female participants consumed whole grain bread 19,57±30,46 g and 31,25±33,14 g respectively. A similar study highlighted that whole grain bread consumption was for male 17.6±25.7 g and for female 45.4±68.1 g (Sari, 2018). Therefore, male participants in present study consumed more whole grain bread than Sari et al., study male participants. This study female participants whole grain bread consumption was lower than female participants in Sari et al., study. On the other hand, a similar study done by Sari et al., found that different types of white bread consumption were 84.8±142.1 g for male participants and 46.6±74.1 g for female participants (Sari, 2018). However, males and females who participated present study consumed different types of white bread 87,59±140,1 g and 16,48±23,31 g respectively. Current study female’s daily consumption of different types of white bread was lower than Acıbadem University study female’s daily consumption. Moreover, this study found that, male participants were consuming 70,49±86,47 g rice and female participants consumed 12,79±13,93 g rice; male participants were consuming 38,88±28,85 g cracked wheat and female participants consumed 10,04±10,83 g cracked wheat; male participants were consuming 41,64±31,88 g pasta and female participants consumed 20,50±23,61 g pasta. However, Sari et al., found that male and female participants consumed rice 43.9±43.3 g and 33.9±68.8 g; cracked wheat 25.1±24.6 g and 20.1±39.1 g; pasta 67.3±79.6 g and 47.1±65.5 g respectively (Sari, 2018). Therefore, males who participated current study consumed more rice and cracked wheat than other study (Sari, 2018) male participants but this situation was opposite for pasta. However, females who participated this study consumed less rice, cracked wheat and pasta than other study females. Lastly, this study participants didn’t consumed any buckwheat and brown rice while males and females who participated other study consumed 0.3±1.0 g and 2.6±12.0 g buckwheat; 6.6±24.1 g and 1.1±5.7 g brown rice respectively (Sari, 2018). There was strong significant difference between males and females for different types of white bread, rice, cracked wheat and pasta in this study (p<0,05).
6. CONCLUSION
As a consequence, it was found that, consumers awareness about term of whole grains, definition of whole grains and description of whole grains don’t differ according to BMI. Also, consumers are not that much aware about recognizing of whole grain products which are multi-grain bread, whole wheat pasta and popcorn. However, consumers’ consumption of whole grains doesn’t change according to BMI except than rye bread. Furthermore, BMI classes doesn’t affect the knowledge of recommended whole grain consumption. Additionally, consumer’s thoughts about whole grains differ according to BMI. While overweight participants like the taste of whole grains, their preferences are white bread. Nevertheless, daily consumption amount of whole grain products doesn’t differ according to BMI but it differs according to gender depends on whole grain products. Consumers’ who thought whole grain bread delicious and/or healthy daily consumption amount of whole grain bread doesn’t differ according to BMI.
7. RECOMMENDATIONS
Consumers should be informed about the importance of whole grains in healthy eating habits. Addition to this, indication of whole grain declarations on product labels should be done more strikingly. Therefore, consumers can notice them more easily. Moreover, promotion of whole grain products which frequently consumed such as bread, pasta and rice should be increased in the markets.
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